Sex Therapy Bristol Blog

Drug treatments for erectile dysfunction (ED) are effective. Millions of men, particularly older men, have been helped to better, more reliable erections. Until the chance discovery less than two decades ago that PDE type-5 inhibitors had a gratifying side impact on men taking the test drugs for heart disease, a man with erectile problems that did not respond to group or psychosexual therapy faced a choice between giving up penetrative sex or resorting to inconvenient, unpleasant and profoundly unsexy vacuum pumps and injections. Sildenafil (aka Viagra) and other PDE type-5 drugs were a positive development for many men. They have also been a welcome boost to the profits of drug companies.

However, erectile dysfunction is a complex and still under-researched condition. Its causes are multifaceted, rarely straightforward and likely to vary widely between men. Heart disease, high blood pressure and diabetes may all make erectile dysfunction more likely. In older men they may be a primary cause. But relationship difficulties, intimacy problems, sexual history, stress, depression, and anxiety may be equally important. In younger men these latter factors are likely to be more significant. However, Big Pharma now dominates this field of sex therapy, and consequently the majority of ED research studies now deal with biological causes and treatments rather than psychosocial factors. Physician training, clinical guidelines and prescription information are all steadily being skewed towards approaching ED as a medical condition to be treated with drugs. In the UK, for example, where cultural factors make a pleasurable sex life a lower health priority, particularly when public health budgets are under pressure, treating ED with a quick and cheap drug script has become the default response for busy doctors, whose only information about erection problems is courtesy of drug companies. Few are likely to recommend the group or individual therapy that has been proven to be equally effective either on its own or in combination with medication. The chances of such talking cures being available on the NHS are even lower.

However, it is on the internet that the marketing muscle of Big Pharma has the greatest potential impact. At present, direct-to-consumer marketing by pharmaceutical companies is only permitted in the USA. But with the internet now the primary source of information about sexual health problems, drug companies can influence consumers anywhere and advertise their products directly and indirectly. A number of studies have now demonstrated that whatever the mental health issue, be it depression, anxiety or OCD, if a website is funded by a drug company, it is more likely to explain a problem in terms of its biological rather than psychosocial causes and recommend a drug treatment¹.

A recent study from New Zealand shows that the same trend is underway on websites dealing with ED². The research reviewed some 70 websites that dealt with erectile problems, mostly from the USA and the UK. Nearly half were either drug company sites, sites that explicitly acknowledged pharmaceutical funding, or sites that took drug company advertising. Yet even though half the sites were nominally independent of pharma money, the bias towards biological causes and treatments in site information was clear. For every ED website that emphasized psychosocial causes, 18 emphasized biological causes. For every website that emphasized psychosocial treatments, 27 emphasized biological treatments. Overall, 77% of the websites put the greatest weight on pharmaceutical treatment, a figure that predictably rose to 90% for pharma-funded sites.

So a man looking for information on the web about why he might be experiencing ED and what he might do about it is most likely to be told that his problem is physical and that drug treatment will sort it out. The same will apply to a professional physician looking for information on behalf of patients. Both lay person and professional are likely to be misled about what is available in terms of effective treatments. Many men may only receive a treatment that, while it might be effective in terms of erections, is unlikely to address the potentially multiple causes of their difficulties, be they relationship problems, depression or anxiety. Judging by the clients who eventually come to me for treatment, PDE type-5 drugs restore erections only temporarily. The underlying psychological and social causes ensure it returns.

The bias towards medication amounts to a direct or indirect theft of choice from the individual man. If this were not bad enough, it also potentially raises the level of stigma surrounding the experience of ED. Persuading someone that their mental health issue is a biologically based illness has been shown to actually increase rather than decrease stigma and prejudice³. The condition becomes a permanent characteristic of the individual rather than a reaction to life events or circumstances. In contrast, belief in psychosocial causes is associated with more positive attitudes and reduced prejudice. The same is likely to be true of ED, although the chances of anyone funding research to find that out is unlikely given the above. Moreover, if biology is all in terms of ED, the penis becomes just a malfunctioning machine. Many men’s attitudes to sex and sexuality are far too mechanical already, so treating the penis as a bit of faulty kit, devoid of the context of each man’s unique life history, anxieties and relationships, fundamentally devalues male sexual functioning and response.

So far, so negative. However, although the internet appears to be the area where ED information and advice is most biased towards the interests of the pharmaceutical industry, it also offers men a forum to take back the initiative, start sharing experiences of ED and work with one another to recommend possible treatments. The top-down model of information exchange that has dominated advertising and communications for a generation is starting to break down. New social media may yet be dominated by the existing commercial power structures, but there are many fields of social interaction where individuals are using the web’s power to speak directly to one another and make up their own minds. All it might take is one man experiencing ED to start a blog or a message board that offers honest, unbiased answers to set the ball rolling. Or perhaps a few sex therapists might have the courage to change their working model, stop relying on a diminishing stream of physician referrals, and take their experience of this complex problem online and offer it to men who need information and help. Should these changes begin to happen, you can be sure that Big Pharma will come knocking on the door with the usual blandishments and incentives of advertising and sponsorship. The behaviour of much of the medical profession shows how hard that might be to resist.

1. Mitchell, J., & Read, J. (2012). Attention-deficit hyperactivity disorder, drug companies and the Internet, Clinical Child Psychology and Psychiatry, 17, 121-139.
2. Mati, E., & Read, J. (2013). Erectile Dysfunction and the Internet: Drug Company Manipulation of Public and Professional Opinion, Journal of Sex & Marital Therapy, 39:6, 541-559.
3. Angermeyer, M., Holzinger, A., Carta, M., & Schomerus, G. (2011). Biogenetic explanations and public acceptance of mental illness, British Journal of Psychiatry, 199, 367-372.